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Diagnostic Radiology

Office of Billing Compliance 2016 Coding, Billing and Documentation Program

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2017 Code Changes

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CPT® 2017 New CodesCode Description76706 Ultrasound, abdominal aorta, real time with image documentation,

screening study for abdominal aortic aneurysm (AAA)

77065 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral

77066 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral

77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed

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CPT® 2017 Revised Codes Code Description77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration,

injection, localization device) (List separately in addition to code for primary procedure)

77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure)

77402 Radiation treatment delivery, >=1 MeV; simple77407 Radiation treatment delivery, >=1 MeV; intermediate

77412 Radiation treatment delivery, >=1 MeV; complex

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Top Billed Diagnostic Radiology CodesCODE PROCEDURES Units %

71010PR CHEST X-RAY 1 VW 52290 30.63%71020CHG CHEST X-RAY 2 VW 17906 10.49%70450PR CT SCAN,HEAD/BRAIN,W/O CONTRAST MATL 12424 7.28%74000PR X-RAY ABDOMEN 1 VW 7317 4.29%70553PR MRI BRAIN COMBO 4562 2.67%71260PR CAT SCAN OF CHEST CONTRAST 4532 2.65%71250PR CT SCAN,THORAX,W/O CONTRAST 3752 2.20%76705US, ABDOMEN LIMITED 3130 1.83%G0202PR SCREENINGMAMMOGRAPHYDIGITAL 2898 1.70%77052PR COMPUTER AIDED MAMMOGRAPHY,SCREENING 2842 1.66%

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Local Coverage Determinations (LCDs)

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Creation and Purpose of LCD

• Local Coverage Determinations (LCDs) are created by the Medicare Administrative Contractor (MAC)

• Local contractor level• Contractor Medical Directors responsibility

• May or may not be associated with a National Coverage Determination (NCD)

• Assist in determining reasonable and necessary criteria• LCDs cannot restrict or conflict with an NCDs

• Or any CMS interpretive manuals

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LCDs

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Local Coverage Determinations (LCDs) for First Coast Service Options, Inc.

Id Title Effective Date

Revision Effective Date

End Date Last Updated Status Select All

L33256

3D Interpretation and Reporting of Imaging Studies

10/01/2015

10/01/2016 N/A 09/28/20

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3D Interpretation and Reporting of Imaging Studies

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On-going Inquiry By CMS76376: 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post-processing under concurrent supervision; not requiring image post-processing on an independent workstation

76377: 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post-processing under concurrent supervision; requiring image post-processing on an independent workstation

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76376 and 76377 - LIMITATIONS• In freestanding and independent diagnostic testing facilities, Medicare expects the referring

physician to generate an appropriate written request indicating the clinical need for the additional 3D imaging, that a copy of that request be maintained by the interpreting physician and the interpreting physician’s report addresses those specific clinical issues. In the event that a 3D interpretation is deemed urgently needed by the radiologist and the referring physician is not immediately available, the radiologist must document the time of the study, the specific need for the study, and a summary of the findings that were urgently transmitted to the practitioner named as the referring physician on the radiology report.

• CPT codes 76376 and 76377 may be considered medically unnecessary and denied if equivalent information obtained from the test has already been provided by another procedure (magnetic resonance imaging, ultrasound, angiography, etc.) or could be provided by a standard CT scan (two-dimensional) without reconstruction.

• Medicare expects that no more than 20 percent of the total Computerized Tomography (CT) and Magnetic Resonance (MR) imaging of any practice be submitted with 3-D rendering or interpretation, with or without image post-processing. However, for cancer evaluation applications, such as staging/monitoring for pulmonary metastases, this threshold may be often exceeded. Therefore, if data suggests providers are billing at higher rates for other indications for 3D rendering, then Medical Review may do pre or post pay reviews to validate the use and medical necessity of the test.

• All imaging studies will be subject to the American College of Radiology Guidelines for reporting.

• CPT code 76376 can be reported when 3D rendering is performed by a radiologist or a specially-trained technologist at the acquisition scanner. However, CPT code 76377 is reported when the 3D post-processing images are reconstructed on an independent workstation with concurrent physician supervision. In order to report 76377, the supervising physician must provide concurrent supervision.

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76376 and 76377 - LIMITATIONS

• In order to report the correct CPT code for the 3D analysis (76376or 76377), it should be documented within the radiology report as to whether the 3D was performed on an independent workstation or on the acquisition scanner. Making an explicit statement within the radiology report will avoid ambiguity, and aid the coder in accurately coding for the 3D reconstruction. Some practices may separately document this in the patient’s electronic medical record, but not actually in the report.

Imaging studies are complex with thousands of individual pictures. Beyond identifying a fracture in an emergency setting a discussion of treatment planning after the patient has left the department is common. 3D may be necessary to understand the anatomy for treatment planning. This discussion occurs after the acute event. Another vignette is an imaging study for stroke but later a seizure concern is identified subsequent to the emergency visit and 3D is applied to evaluate an anatomy of the hippocampus for a seizure focus.

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ICD-10 Codes That Support Medical Necessity

Group 1 Paragraph: Note: All primary diagnosis codes must be related to the primary procedural code when rendered for the 3-D reconstruction. The use of these diagnosis codes implies the medical necessity of the 3-D rendering and interpretation, as outlined in this LCD, is documented in the medical record. A written request for the study from the referring physician must also be in the medical record and made available upon request when performed in freestanding and independent diagnostic testing facilities.The following lists include only those secondary diagnoses for which the identified CPT/HCPCS procedures are covered.

Note: If a covered secondary diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

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Covered ICD-10 Codes for 76376 & 76377Group 1

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ICD-10 DescriptionR90.82 White matter disease, unspecifiedR91.8 Other nonspecific abnormal finding of lung field

R93.0 Abnormal findings on diagnostic imaging of skull and head, not elsewhere classified

R93.1 Abnormal findings on diagnostic imaging of heart and coronary circulation

R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract

R93.4 Abnormal findings on diagnostic imaging of urinary organs

R93.5 Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum

R93.6 Abnormal findings on diagnostic imaging of limbs

R93.7 Abnormal findings on diagnostic imaging of other parts of musculoskeletal system

R93.8 Abnormal findings on diagnostic imaging of other specified body structures

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Covered ICD-10 Codes for 76376 & 76377:Group 2: Covered primary diagnosis for deep

brain stem lead placement only.

ICD-10 Codes DescriptionG20 Parkinson's diseaseG21.4 Vascular parkinsonismG24.1 Genetic torsion dystoniaG24.3 Spasmodic torticollisG24.9 Dystonia, unspecifiedG25.0 Essential tremorG25.1 Drug-induced tremorG25.2 Other specified forms of tremor

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Documentation Requirements

• Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.

• Use of one of the secondary diagnosis codes in this LCD implies medical necessity for 3-D rendering and interpretation.

• Documentation supporting medical necessity must be maintained in the medical record along with the written request for the study from the referring physician.

• 3 D Reconstruction services are to be reported by a separate report or in a separate section of the base service report.

• A permanent archive of 3 D studies of CTA studies is suggested by the ACR.

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ARCHIVING OF IMAGES

• General Principles• All pertinent imaging data should be saved in permanently

retrievable digital or hard-copy format. Examples of pertinent imaging data include:

• The relevant anatomy that will affect patient management, device position, complications, and transient adverse events (such as emboli) that might have been successfully treated during a given procedure.

• If ultrasound guidance is used to gain entry into a blood vessel, it is optional to save a sonographic image of this blood vessel.

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Diagnosis CodingInternational Classification of Disease (ICD-10)

• ICD-10 compliance –• Relying on the information that comes across with each order

to dictate the clinical information section of reports. • Is that sufficient? • Using report templates that pull this information directly

from the order. • For example, the text might read “Special instructions: r/o

pulmonary embolism” along with the actual ICD-10 code.• What is the best approach?

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Choosing the Primary ICD-10 CodeConfirmed Diagnosis Based on Results of Test

• Report any confirmed diagnosis• Signs and/or symptoms may be reported as additional

diagnoses• Signs/Symptoms

If the diagnostic test did not provide a diagnosis or was normal, the interpreting physician should code the sign(s) or symptom(s) that prompted the treating physician to order the study.• “On the rare occasion when the interpreting physician does not

have diagnostic information as the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient’s medical record if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician.” (Language removed in latest version of MCPM Chapter 23, Section 10.1.2

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Choosing the Primary ICD-10 Code• Uncertainty: Considered by the ICD-10-CM Coding

Guidelines as unconfirmed and should not be reportedDo not code the following diagnoses:

• Probable• Suspected• Questionable• Rule out• Working diagnosis• Other similar terms indicating uncertainty.

Code to the highest degree of certainty (symptoms, signs, abnormal test results, or other reason for the visit)

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Modifiers

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Consultation on Previous Interpretation

• 77 Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional: It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service.

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“Second Reads”

Reference Medicare Claims Processing Manual, Chapter 13, Radiology Services and Other Diagnostic Procedures (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c13.pdf “Generally, carriers must pay for only one interpretation of an EKG or x-ray procedure furnished to an emergency room patient. They pay for a second interpretation (which may be identified through the use of modifier “-77”) only under unusual circumstances (for which documentation is provided) such as a questionable finding for which the physician performing the initial interpretation believes another physician’s expertise is needed or a changed diagnosis resulting from a second interpretation of the results of the procedure.” -

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Modifier 76 Fact Sheet

Repeat Procedure by the Same Physician; use when it is necessary to report repeat procedures performed on the same day.• Appropriate Usage

• On procedure codes that cannot be quantity billed• Report each service on a separate line, using a quantity of one and append

76 to the subsequent procedures• The same physician performs the services

• Inappropriate Usage• Repeat services due to equipment or other technical failure• For services repeated for quality control purposes

• Additional Information• Medicare considers two physicians, in the same group with the same

specialty performing services on the same day as the same physician

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CPT Code 76140: Consultation on X-ray examination made elsewhere, written reportYou should only report 76140 if a physician from another institution requests your physician's opinion on a radiograph and you send that physician your interpretation. You should not report 76140 if a physician within your practice or hospital asks you to reread an x-ray that was primarily interpreted by another physician within the same practice. Instead, report 76140 when you interpret an imaging study that was primarily obtained and interpreted by a physician from a different practice and with a different provider number.

Medicare and some private payers assign "0" relative value units to 76140 and will not reimburse you for this service. If your commercial insurer allows payment for this service, ask for the coverage guidelines in writing before billing 76140 to avoid unnecessary denials. Your practice should establish a policy related to billing the patient for reinterpretations of outside films. If you intend to bill for this service, you should obtain an advance beneficiary notice for patients whose payers do not provide payment for 76140.

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Referring/Treating Physician and Orders

• Orders must be specific to the diagnostic test requested.

• Diagnostic tests require documentation of the name of the referring/ordering provider.

• Absent a valid ordering provider the claim will be denied.

• Notations such as “ Chest X-ray requested by Cardiology Service” are not acceptable – must be “person” specific

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Treating Practitioner to Order all Tests• Limited exceptions:

• Allows additional testing to be done by the radiologist prior to or without contacting the treating physician/practitioner, when the radiologist determines that based on the result of an ordered diagnostic test, an additional diagnostic test should be performed. All of the following criteria must be met:

• The diagnostic test ordered by the treating practitioner is performed;

• Radiologist determines and documents that, because of the abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary;

• A delay in additional diagnostic testing would have an adverse effect on the care of the patient;

• The result of the test is communicated to and is used by the treating practitioner in the treatment of the patient; and

• The radiologist documents in his/her report why additional testing was done.

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The Interpreting Physician May:• Determine the test design, unless specified in the order.

• The interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (e.g., number of radiographic views obtained, thickness of tomographic sections acquired, use or non-use of contrast media).

• An order for “MRI of orbit” without a specific contrast component would allow the interpreting physician to determine if contrast was medically appropriate for that specific patient without obtaining an updated order.

• Modify, without notifying the treating physician/practitioner, an order with clear and obvious errors that would be apparent to a reasonable layperson, such as the patient receiving the test (e.g., x-ray of wrong foot ordered).

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Conditional Orders• CMS has approved the use of conditional orders as long as they

are limited to a specific patient. • Example: a patient-specific order reads: “Diagnostic

mammogram of right breast with ultrasound, as indicated,” the radiologist may add the ultrasound to characterize the mass.

• A standing order for all patients of a given treating physician/practitioner (e.g., “if gallbladder ultrasound for Dr. Smith is negative, do UGI”) is not acceptable. The conditional order process can be replicated across diagnostic testing modalities (i.e., CT; MRI; Ultrasound; etc) with the understanding that such conditional orders MUST BE patient-specific.

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Radiological Reports

• Elements of the report• Clinical Information must include:

• Referring/ordering Physician• Patient Demographics (unless readily available in the EMR) • Clinical signs or symptoms or personal history of disease

• Body of the report should include• Description of the procedure including anatomical area, modality, and

use of contrast. • Describes if and why additional testing was done.

• Impression • Revises or confirms initial diagnosis• If findings are negative – coding is based on signs or symptoms

• All coding must be abstracted from the Body of the report and not from headers.

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This becomes crucial in cases with negative or inconclusive findings!

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Documentation Tips for MultipleProcedures

List all of the radiological tests reviewed/performed•Indicate pertinent history of present illness•Specify anatomical site(s)•Include number of views if applicable•Indicate if contrast has been used

Assure that test-specific interpretation is documented within the body of the report for all reviewed tests

• E.g. : Chest CT scan w/o contrast and Abdominal CT with and w/o contrast

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Lack of documentation = loss of revenue

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Billing Services When Working With Residents Fellows and Interns

All Types of Services Involving a resident with a TP Requires Appropriate Attestations In EHR or Paper Charts To Bill

Teaching Physicians (TP) Guidelines

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• RADIOLOGY AND OTHER DIAGNOSTIC TESTS• General Rule: The Teaching Physician may bill for the interpretation of Diagnostic

Radiology and other diagnostic tests if the interpretation is performed or reviewed by the Teaching Physician with modifier 26 in the hospital setting.

• Teaching Physician Documentation Requirements:• Teaching Physician prepares and documents the interpretation report.• OR• Resident prepares and documents the interpretation report• The Teaching Physician must document/dictate: “I personally reviewed the

film/recording/specimen/images and the resident’s findings and agree with the final report”.

• A countersignature by the Teaching Physician to the resident’s interpretation is not sufficient documentation.

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Diagnostic Procedures

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Minor – (< 5 Minutes): For payment, a minor procedure billed by a TP requires that s/he is physically present during the entire procedure.

Example: ‘I personally performed the procedure’Example: ‘I was present for the entire procedure.’

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TP Guidelines for Procedures

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• TEACHING PHYSICIANS WHO SEEK REIMBURSEMENT FOR OVERSIGHT OF PATIENT CARE BY A RESIDENT MUST PERSONALLY SUPERVISE ALL SERVICES PERFORMED BY THE RESIDENT.

• PERSONAL SUPERVISION PURSUANT TO RULE 59G-1.010(276), F.C.A, MEANS THAT THE SERVICES ARE FURNISHED WHILE THE SUPERVISING PRACTITIONER IS IN THE BUILDING AND THAT THE SUPERVISING PRACTITIONER SIGNS AND DATES THE MEDICAL RECORDS (CHART) WITHIN 24 HOURS OF THE PROVISION OF THE SERVICE.

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Florida Medicaid Teaching Physician Guidelines

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Modifier GC CMS Manual Part 3 - Claims Process - Transmittal

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Teaching Physician Services That Meet the Requirement for Presence During the Key Portion of the Service when working with a resident or fellow

Teaching Physician Services that are billed using this modifier are certifying that they have been present during the key portion of the service.

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Inpatient and Outpatient

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Evaluation and Management E/MDocumentation and Coding

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Putting The Puzzle Together

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Ignoring how medical decision-making affects E/M leveling can put you at risk.

• According to the Medicare Claims Processing Manual, chapter 12, section 30.6.1:

• Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.

• That is, a provider should not perform or order work (or bill a higher level of service) if it’s not “necessary,” based on the nature of the presenting problem.

Medical Necessity

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The 3 Key Documentation Elements

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Medical Decision Making

Physical Exam

History Focus on HPI

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Elements of an E/M History• The extent of information gathered for history is dependent

upon clinical judgment and nature of the presenting problem. Documentation of the patient’s history includes some or all of the following elements:

• Chief Complaint (CC) & History of Present Illness (HPI)• WHY IS THE PATIENT BEING SEEN TODAY

• Review of Systems (ROS) related to HPI,• Past Family, Social History (PFSH) related to HPI.

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Focus on the Present Illness or Reason for the Encounter

3

X

X XX X

XX

XXX

X

X

X

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EXAMINATION

• 4 TYPES OF EXAMS

• Problem focused (PF)• Expanded problem focused (EPF) • Detailed (D)• Comprehensive (C)

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1995: Physical Exam

• Head, including face• Neck• Chest, including breast and axillae• Abdomen

• Genitalia, groin, buttocks• Back, including spine• Each extremity

BODY AREAS (BA):

CODING ORGAN SYSTEMS (OS):

Constitutional/General Eyes Ears/Nose/Mouth/Throat Respiratory Cardiac GI

GU Musculoskeletal Skin Neuro Psychiatric Hematologic/Lymphatic

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PHYSICAL EXAM: General Multi-System Examination ( BA/OS) Elements of Examination

BA Head, including the faceBA Neck: neck (masses, symmetry, etc); thyroidBA Chest (Breasts): inspection breast; palpation breast/axillaeBA AbdomenBA Genitalia, groin, buttocks BA Back, including spine BA Left upper extremity BA Right upper extremity BA Left lower extremity BA Right lower extremity

OS Constitutional: vitals (sit/stand BP; sup BP; temp; pulse rate; resp; ht; wt) or General appearanceOS Eyes: conjunctivae/lids; pupils/irises; optic discsOS Ears, Nose, Mouth/Throat: exam ears/ nose; exam auditory canal/tympanic membrane; hearing

assessment; Exam nasal mucosa/septum/turbinates; exam lips/teeth/gums; exam oropharynx/palates

OS Respiratory: respiratory effort; percussion of chest; palpation of chest; auscultation of lungsOS Cardiovascular: palpation heart; auscultation; Exam of: carotid; femoral arteries; abd aorta; pedal pulses; Exam extremities for edema/varicositiesOS Gastrointestinal: exam of abd; exam liver/spleen; hernia +/-; exam anus, perineum, rectum; stool specimen

if appropriateOS Genitourinary: Male: exam of scrotum; exam of penis; DRE of prostate;

Female: exam ext genitalia, vagina, urethra, bladder, cervix, uterus, adnexa/parametriaOS Musculoskeletal: gait/station; inspect digits/nails; inspect/ROM/stability/strength of head/neck, spine/rib/pelvis (Rt upper, Lt upper, Rt lower, Lt lower extremities can be OS also)OS Skin: inspect skin/subcutaneous tissue; palpation skin/subcutaneous tissueOS Neurologic: test cranial nerves; deep tendon reflexes, sensationsOS Psychiatric: judgment/ insight; orientation to person/place/time; recent/remote memory; mood & affectOS Hematological/lymphatic palpation of nodes neck, axillae, groin, other

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X

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Medical Decision MakingDOCUMENT EVERYTHING THAT EFFECTS YOUR SERVICE!! Include all diagnosis that impact the service.

• Number of possible diagnosis and/or the number of management options.Step 1:

• Amount and/or complexity of data reviewed, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed.Step 2:

• The risk of significant complications, morbidity, and/or mortality with the patient’s problem(s), diagnostic procedure(s), and/or possible management options.Step 3:

Note: The 2 most complex elements out of 3 will determine the overall level of MDM

Exchange of clinically reasonable and necessary information and the use of this information in the clinical management of the patient

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Using Time to Code an E/M

Time shall be considered for coding an E/M in lieu of H-E-MDM when > 50% of the total billable practitioner visit time is counseling/coordination of

care (CCC.) Time is only Face-to-face for OP setting

• Coding based on time is generally the exception & is typically used for:• Exacerbation or change in the patient’s condition or new diagnosis, • Non-compliance with the treatment/plan, • Counseling regarding previously performed procedures or tests to

determine future treatment optionsIssues that may not lend themselves to typical E/M encounter. Examples:

• Behavior/school issues, ADHA• Non-compliance with medications or treatments• Introduction of new medications or treatments

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Using Time to Code an E/M

Required Documentation For Billing:1. Total time of the encounter excluding separate

procedure if billed2. The amount of time dedicated CCC for that

patient on that date of service. 3. A template statement would not meet the

documentation requirements.4. The documentation MUST be individualized for

each patient visit!5. Check boxes for time and check boxes for CCC

are NOT acceptable for coding an E/M service based on time.

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What is Counseling of CareReport on Medicare Compliance August 22, 2016

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Counseling of Care DefinitionThe CPT manual makes a distinction between psychotherapy and counseling. Counseling is defined as a discussion with a patient and/or family concerning one or more of the following areas:

• Diagnostic results, impressions, and/or recommended diagnostic studies;• Prognosis;• Risks and benefits of management (treatment) options;• Instructions for management (treatment) and/or follow-up;• Importance of compliance with chosen management (treatment) options;• Risk factor reduction;• Patient and family education.

The CPT manual is not explicit in its definition of coordination of care, but the Agency for Healthcare Research and Quality (“AHRQ”) developed the following definition:

“Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves marshalling of personnel and other resources needed to carry out all required patient activities, and is often managed by the exchange of information among participants responsible for different aspects of care.”*.

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What is Coordination of CareReport on Medicare Compliance August 22, 2016

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Selection of the Level of E/M VisitMedicare instructs providers to select the procedure or service that accurately identifies the service performed. If that is an E/M service, the provider determines the extent of the history obtained, the extent of the examination performed and the complexity of the medical decision making. If for some reason, counseling and/or coordination of care dominates (more than 50% of the total time of the encounter) with the patient and/or family (face to face time in the office or other outpatient setting or floor/unit time in the hospital), then time shall be considered the key or controlling factor to qualify for a particular level of E/M service. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (i.e. foster parents, legal guardians). The content of the corresponding patient clinical note should document the nature of the medical counseling and explicitly what topics were discussed in the coordination of care.

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Counseling/Coordination of Care CCCProper Language used in documentation of time:• “I spent ____ minutes with the patient and family and over 50% was in counseling

about her diagnosis, treatment options including _______ and ______.”

• “I spent ____ minutes with the patient and family more than half of the time was spent discussing the risks and benefits of treatment with……(list risks and benefits and specific treatment)”

• “This entire ______ minute visit was spent counseling the patient regarding ________ and addressing their multiple questions.

Total time spent and the time spent on counseling and/or coordination of care must be documented in the medical record.

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Documentation must reflect the specific issues discussed with patient present.

Document the specific topics that were discussed during the counseling (i.e. diagnosis, prognosis, treatment options, medical management and side effects, etc).

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Outpatient Counseling Time:99201 10 min99202 20 min99203 30 min99204 45 min99205 60 min

99241 15 min99242 30 min99243 40 min99244 60 min99245 80 min

99211 5 min99212 10 min99213 15 min99214 25 min99215 40 min

Inpatient Counseling Time:

99221 30 min99222 50 min99223 70 min

99231 15 min99232 25 min99233 35 min

99251 20 min99252 40 min99253 55 min99254 80 min99255 110 min

Time-Based Billing for CCC

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XXX

Time

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Completing the Puzzle

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Scoring Medical Records

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Evaluation & Management Coding Card

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Evaluation & Management Coding

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Prolonged Non Face-to-Face Time99358: Prolonged evaluation and management service before and/or after direct patient care; first hour99359: each additional 30 minutes with a maximum of 2 units• Report this service if the provider spends time in either preparation or evaluation of the

outcome of treatment before or after the face–to–face encounter with a patient.Clinical Responsibility: For these service, the provider puts extra effort and time into the treatment of the patient. For example, the provider evaluates the patient’s previous records in cases where the patient opted to change his provider and the new provider performs extra work to understand and plan the treatment of the patient. The provider can also invest extra time to review the reports and progress after the patient has undergone treatment.Codes 99358 and 99359 are used when a prolonged service is provided that is neither face-to-face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service and is beyond the usual physician or other qualified health care professional service time.

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Code Status A

Medicare Fees

National Local 26 TC 53

99358 $113.41 $122.65 $0.00 $0.00 $0.00

99359 $54.55 $58.89 $0.00 $0.00 $0.00

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Prolonged Non Face-to-Face TimeThis prolonged service may be reported on a different date than the primary service to which it is related. For example, extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records. However, it must relate to a service or patient where (face-to-face) patient care has occurred or will occur and relate to ongoing patient management.

Codes 99358 and 99359 are used to report the total duration of non-face-to-face time spent by a physician or other qualified health care professional on a given date providing prolonged service, even if the time spent by the physician or other qualified health care professional on that date is not continuous.

• Code 99358 is used to report the first hour of prolonged service (cannot bill if <30 minutes of time) on a given date regardless of the place of service. It should be used only once per date.

• Code 99359 is used to report each additional 30 minutes beyond the first hour regardless of the place of service. It may also be used to report the final 15 to 30 minutes of prolonged service on a given date.

• Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

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REGULATIONS PER CMS: The medical record must be documented by the practitioner to include the dated start and end times of any prolonged service.

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HIPAA, HITECH, PRIVACY AND SECURITY• HIPAA, HITECH, Privacy & Security Health Insurance Portability and Accountability Act – HIPAA

– Protect the privacy of a patient’s personal health information– Access information for business purposes only and only the records you need to

complete your work.– Notify Office of HIPAA Privacy and Security at 305-243-5000 if you become

aware of a potential or actual inappropriate use or disclosure of PHI,including the sharing of user names or passwords.

– PHI is protected even after a patient’s death!!!

• Never share your password with anyone and no one use someone else’s password for any reason, ever –even if instructed to do so.

If asked to share a password, report immediately.If you haven’t completed the HIPAA Privacy & Security Awareness on-line CBLmodule, please do so as soon as possible by going to:

http://www.miami.edu/index.php/professional_development__training_office/learning/ulearn/

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HIPAA, HITECH, PRIVACY AND SECURITYHIPAA, HITECH, Privacy & SecuritySeveral breaches were discovered at the University of Miami, one of which has resulted in a class action suit. As a result, “Fair Warning” was implemented.What is Fair Warning?

• Fair Warning is a system that protects patient privacy in the Electronic Health Record by detecting patterns of violations of HIPAA rules, based on pre-determined analytics.• Fair Warning protects against identity theft, fraud and other crimes that compromise patient confidentiality and protects the institution against legal actions.• Fair Warning is an initiative intended to reduce the cost and complexity of HIPAA auditing.

UHealth has policies and procedures that serve to protect patient information (PHI) in oral, written, and electronic form. These are available on the Office of HIPAA Privacy & Security website: http://www.med.miami.edu/hipaa

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Available Resources at University of Miami, UHealth and the Miller School of Medicine

• If you have any questions or concern regarding coding, billing, documentation, and regulatory requirements issues, please contact:

• Helenmarie Blake-Leger, Interim AVP of Compliance & Chief Privacy Officer Phone: (305) 243-6000

• Iliana De La Cruz, RMC, Executive Director, Professional Billing Compliance• Gema Balbin-Rodriguez, Director, Professional Billing Compliance

• Phone: (305) 243-5842 • Email: Officeofbillingcompliance@med.Miami.edu

Also available is The University’s fraud and compliance hotline via the web at www.canewatch.ethicspoint.com or toll-free at 877-415-4357 (24hours a day, seven days a week). Your inquiry or report may remain anonymous

• Office of billing Compliance website: www.obc.med.miami.edu

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